Connecticut Long Term Care Ombudsman Program


Using Care Planning to Resolve Problems

Long term care residents have the right to make choices about care, services, daily schedule and activities, and to be involved in the planning of their care.

An effective care plan should:

  • Be specific, individualized and written in language that everyone can understand.
  • Reflect the resident’s concerns, and support her/his wellbeing, functioning and rights.
  • Use a multi-disciplinary team approach and utilize outside referrals if needed.
  • Be re-evaluated and revised routinely.

Here are some ways in which residents and their family members can be more involved in the care planning process:

Residents:

  • Before the care plan meeting think about your questions, concerns and expectations. Ask your doctor or the staff about your condition, care and treatment. Ask the staff to hold the meeting when your family can attend, if you want them there.
  • During the meeting ask about different options for treatments. Be sure that medical terms and procedures are explained fully to you. Ask for a copy of the care plan and find out whom to talk to if you want to change it.
  • After the meeting, be sure that your care plan is being followed, and let staff know if it is not.

Families:

  • Support your relative’s agenda, choices and participation in the meeting.
  • Involve your relative as much as possible in care planning even if s/he has cognitive or communication problems. Always assume that s/he may understand and be able to communicate at some level.
  • Share with staff the ways you have learned to communicate with your relative and what preferences s/he may have that are not being communicated otherwise. Observed how the care plan is being followed.
  • Work with staff to make changes if problems arise.

Beware of care plans that:

  • Incorrectly label behaviors as problems.
  • Are driven by staff problems not resident’s problems.
  • Have goals and objectives that are too broad or not individualized.
  • Do not reflect the resident’s concerns and preferences.
  • Do not have the resident’s agreement.
  • Do not address needs identified in the assessment.
  • Are outdated or never change.
  • Contain conflicting goals from different disciplines.
  • Are difficult to understand.

Participating in a care plan conference can be helpful when:

  • Residents and families need information.
  • Residents or family members have concerns about delivery of services.
  • Several people need to be present to resolve a problem.
  • The facility’s complaint process has failed.
  • The facility is not following an established plan of care.
  • The resident receives a discharge notice.